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Medical History

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Medical History Powered By Docstoc
					                                                                                         Date______________

   www.plasticsurgerycorner.com             PATIENT MEDICAL/SURGICAL HISTORY
Paul D. Feldman, M.D., F.A.C.S., F.I.C.S.
   Edward S. Gronka, M.D. F.A.C.S.
      Joseph Raniere Jr., F.A.C.S.


                                                                   __________________________________
   What would you like to discuss with the doctor today?____________

   In an effort to help us provide better care for you, please complete the following history (in black or blue ink).
   Medical/Surgical History - Please check in the left column if you have or have had the following:
PAST MEDICAL HISTORY
                        Problem                                                             Comments
Cardiovascular: (heart, blood vessels)                        None
       Chest Pain/Heart Attack
       Palpitations (“skipping” heart beat; racing feeling)
       High Blood Pressure
       Mitral Valve Prolapse/Murmur
       Open Heart Surgery/Angioplasty
       Pacemaker
       Blood Vessel surgery
       Other           High Cholestrol
Respiratory: (lungs, breathing)                               None
       Asthma
       Tuberculosis (TB)
       Shortness of Breath
       Emphysema
       Pneumonia/bronchitis
       Sleep Apnea        Other:
GI/Liver Disease:                                             None
       Hepatitis          Jaundice
       Cirrhosis          Reflux / GERD
       Ulcer              Hernia
       Gallbladder        Appendectomy
       Other
Cancer:                                                       None
       Location:
       Treatment:
Neuromuscular Disease: (nerve, muscles)                       None
       Stroke
       Seizures or convulsions
       Paralysis
       Other
Trauma (car accident, fall, etc.)                             None
Describe:
What is your current Height:________
                         Weight:________
                                              Page 1 of 5                       Patient Sticker
                       Problem                                       Nurse’s Comments
Wound Healing Problems                                 None
       If yes, Describe:
Endocrine: (glands)                                    None
       Diabetes
       Thyroid Disease     Other:
Musculoskeletal: (muscles, bones, joints)              None
       Arthritis
       Lupus
       Bursitis
       Fractures (broken bones)
       Joint Replacement
       Other:
Ears, Nose, Throat:        Other:                      None
       Describe:
Genitourinary: (bladder, kidney)                       None
       Bladder Infection
       Kidney Infection
       Kidney Stones
       Kidney Disease
       Other:
Skin Disease:                                          None
       Eczema
       Dermatitis
       Psoriasis           Other:
Eye Disease:                                           None
       Glaucoma
       Cataracts           Other:
Blood Disorder:                                        None
       Sickle Cell         Trait
       HIV/AIDS            Disease
       DVT’S               Other:
Previous Psychiatric Treatment:                        None
       Describe:
Reproductive:                                          None
       Breast Surgery       Last Mammogram?
       Hysterectomy        Last Pap smear?
       Pregnant # Children            Birth Control:
       Testicular Disease/Surgery
       Prostate Surgery    Last prostate exam?
       Sexual Transmitted Disease        Type:
       Other:
       No Menstrual periods
Patient History                       Page 2 of 5             Patient Sticker

				
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Description: Medical history worksheet for patients at Advanced Aesthetics